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Vol. ~ EINet News Briefs ~ Mar 21, 2008


*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and notifications for emerging infections affecting the APEC member economies. It was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:

1. Influenza News
- Global: Cumulative number of human cases of avian influenza A/(H5N1)
- Global: Time to acknowledge social and economic effects of H5N1 avian influenza, experts say
- Turkey (Edirne): Backyard chickens infected with H5N1 avian influenza
- Hong Kong: Schools shut due to outbreaks of seasonal influenza
- Indonesia: H5N1 avian influenza and H3N2 seasonal influenza co-infection in Indonesian teenager
- Laos: Government officials report a new outbreak of H5N1 avian influenza in poultry
- Viet Nam (Quang Nam): H5N1 avian influenza outbreak in ducks
- USA: US has enough H5N1 avian influenza vaccine for 13 million people
- USA: New patch boosts immunity to H5N1 avian influenza
- China (Guangdong): Officials report H5N1 avian influenza outbreak in poultry
- Viet Nam: Vietnamese child dies from H5N1 avian influenza, country's 106th case/52nd death

2. Infectious Disease News
- Australia (New South Wales): Rise in mosquito-borne illnesses prompts bite warning
- Australia (Queensland): Measles outbreak spreads to mine workers
- Australia: Number of dengue fever cases rising in Port Douglas
- Philippines (Laguna, Iloilo): Typhoid outbreaks sicken thousands, deaths reported
- Thailand (Prachuap Khiri Khan): Economy reports first case of Tularemia
- Canada (Chilliwack): Health officials report five cases of lab-confirmed mumps
- Canada: Eight family members sickened by unknown illness
- USA: Experts closing in on heparin contaminant
- USA (Virginia): Imported case of measles worries U.S. health officials
- USA: Officials report three new cases of hantavirus
- USA (Arizona): Second case of measles confirmed at Northwest Medical Center
- USA (Nebraska): Progressive inflammatory neuropathy in pork plant worker

3. Updates
- AVIAN PANDEMIC INFLUENZA
- Indonesia (FAO report)

4. Articles
- A survey of knowledge, attitudes and practices towards avian influenza in an adult population of Italy
- A broadly protective vaccine against globally dispersed clade 1 and clade 2 H5N1 influenza viruses
- Current and future antiviral therapy of severe seasonal and avian influenza.
- The Southeast Asian Influenza Clinical Research Network: Development and challenges for a new multilateral research endeavor
- Ecology of H3 avian influenza viruses in Korea and assessment of their pathogenic potentials

5. Notifications
- APEC EINet Pandemic Influenza Preparedness Virtual Symposium: Partnerships and Continuity Planning for Critical Systems
- 13th International Congress on Infectious Diseases (ICID)
- HHS includes online services in pandemic communication drill


1. Influenza News

Global
Global: Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)

2008
China / 3 (3)
Egypt / 4 (1)
Indonesia / 12 (10)
Viet Nam / 5 (5)
Total / 24 (19)

2007
Cambodia / 1 (1)
China / 5 (3)
Egypt / 25 (9)
Indonesia / 42 (36)
Laos / 2 (2)
Myanmar / 1 (0)
Nigeria / 1 (1)
Pakistan / 1 (1)
Viet Nam 8 (5)
Total / 86 (58)

2006
Azerbaijan / 8 (5)
Cambodia / 2 (2)
China / 13 (8)
Djibouti / 1 (0)
Egypt / 18 (10)
Indonesia / 56 (46)
Iraq / 3 (2)
Thailand / 3 (3)
Turkey / 12 (4)
Total / 116 (80)

2005
Cambodia / 4 (4)
China / 8 (5)
Indonesia / 17 (11)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 95 (41)

2004
Thailand / 17 (12)
Viet Nam / 29 (20)
Total / 46 (32)

2003
Viet Nam / 3 (3)
Total / 3 (3)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 373(236).
(WHO 3.18.07 http://www.who.int/csr/disease/avian_influenza/en/index.html )

Avian influenza age distribution data from WHO/WPRO: http://www.wpro.who.int/sites/csr/data/data_Graphs.htm .
(WHO/WPRO 3.5.08)

WHO's maps showing world's areas affected by H5N1 avian influenza (last updated 3.18.08):
http://gamapserver.who.int/mapLibrary/

WHO’s timeline of important H5N1-related events (last updated 3.11.07):
>http://www.who.int/csr/disease/avian_influenza/ai_timeline/en/index.html

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Global: Time to acknowledge social and economic effects of H5N1 avian influenza, experts say
More than 10 years after the first appearance of avian influenza H5N1, experts believe it is time to acknowledge that the virus has become entrenched in many areas and to begin grappling with its social and economic effects. Speaking at the biennial International Conference on Emerging Infectious Diseases, senior animal-health scientists urged their human-health colleagues to focus on the many non-science issues—from agricultural traditions to food needs to gender relations—that are complicating avian flu control.

H5N1's potential for causing a human pandemic has understandably been the major focus of research, the scientists acknowledged. But "for every human being infected, there is at least one million animals infected—and that is probably an underestimate," Dr. Ilaria Capua, the head of virology at Italy's Istituto Zooprofilattico Sperimentale delle Venezie, said. "The veterinary community . . . have never before faced a challenge this big."

The economic repercussions reach from the micro level of village markets to the macro level of national economies and back, said Dr. Alejandro Thiermann, special advisor to the director-general of the World Organization for Animal Health. Fearing the importation of H5N1 flu, some countries have banned imports of chicken produced in affected countries, even when the disease has been found in wild birds rather than poultry. The resulting collapse in trade within a country depresses the prices that small-scale growers earn and makes them less willing to report disease outbreaks. The problem has proved so significant that new provisions governing avian flu-related trade restrictions are being added to the Animal Terrestrial Code, an international treaty governing veterinary health, said Thiermann, who serves as the Code's secretary.

The adoption of widespread poultry vaccination, one of the chief tools for controlling avian flu, also illustrates the complexity of integrating flu control into cultures and economies, said Dr. Les Sims of Australia's Asia-Pacific Veterinary Information Services. Stringent vaccination has successfully controlled avian flu in Hong Kong since late 2003, Sims said, but Hong Kong is "small and rich" and its results have not been replicated in any other country where avian flu is endemic. "We knew that mass vaccination would be very difficult to sustain, both the financial cost to the government and the enthusiasm of the people to go out and support it," he said. "The problems that are occurring in Vietnam now are largely ones that appear to be due to farmers not having their birds vaccinated rather than to vaccine failure."

Successful avian flu control will require attention to these and other "last-mile" difficulties that are not usually the province of virologists or human-health planners, the scientists cautioned.
(CIDRAP 3.18.08)

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Europe/Near East
Turkey (Edirne): Backyard chickens infected with H5N1 avian influenza
Veterinary officials in Turkey have confirmed an H5N1 avian influenza outbreak in the western part of the country near the border with Greece, according to a report on 8 Mar 2008 from the World Organization for Animal Health (OIE). The virus struck 22 backyard chickens at a village near Ipsala in Edirne province. The remaining 16 birds were destroyed. Turkish officials listed fomites, which could involve contamination spread by humans, vehicles, or animal feed, as the source of the outbreak. Turkey's last H5N1 outbreaks occurred over several weeks in January and February 2008 at six sites, all of which involved backyard poultry.

All of the previous outbreaks occurred near villages along the Black Sea, an area that officials from the United Nations Food and Agriculture Organization (FAO) have said is vulnerable to H5N1 outbreaks, because surrounding countries are a winter home to migratory birds from Siberia and often have poor separation between wild and domestic birds. In contrast to previous outbreaks, the Ipsala area is close to the Mediterranean Sea.
(ProMED 3.20.08)

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Asia
Hong Kong: Schools shut due to outbreaks of seasonal influenza
Hong Kong's top health official announced on 12 Mar 2008 that all primary schools, special schools and kindergartens in the city would close for two weeks due to seasonal flu outbreaks. Dr. York Chow, secretary for Food and Health of Hong Kong Special Administrative Region (HKSAR) government made the announcement after the Department of Health and the Bureau of Education met to review the data of the flu and the response of parents.

"We made the decision given the rising trend of flu infections within the community as the flu peak is expected to continue for weeks," Chow said. "We hope such precautionary measures will help reduce the cross infection of the flu virus in schools and the community."

Chow said that an expert group was doing its best to investigate the recent deaths of three children with flu-like symptoms, adding that at this stage, no common factors have been identified. He said the most important thing at the moment is to grasp a clear picture of the outbreaks and whether they are spreading. On 12 March 2008, the Center for Health Protection (CHP) of the Department of Health (DH) received reports of influenza-like illness (ILI) outbreaks affecting 23 schools involving a total of 184 people. A CHP spokesman said ILI could be caused by influenza or other respiratory viruses. CHP's officials have visited all these institutions and provided health advice to the staff accordingly.

CHP received a report from Hospital Authority on 12 March 2008 concerning a three-year-old boy who was admitted to Princess Margaret Hospital because of persistent fever, cough, and shortness of breath. The boy was transferred to Intensive Care Unit and is now in stable condition, said the spokesman, adding that initial investigation showed his respiratory sample yielded positive results for influenza A (H1N1). Further tests are in progress. Regarding the death of a 7-year-old boy with respiratory and neurological symptoms in Tuen Mun Hospital, the spokesman said further laboratory tests showed that the boy's respiratory sample yielded positive results for influenza A (H1N1) (other reports maintain that it was a dual H1 and H3 infection). A three-year-old girl also died of the flu early this month, following the death of a two-year-old child at the end of February 2008. Hong Kong health officials have reported nine confirmed flu cases and 65 suspected ones since 6 Mar 2008, mostly at schools, in the territory of nearly seven million.

The Hospital Authority (HA) on 12 Mar 2008 announced that a special fund of 20 million HK dollars (2.6 million USD) had been set aside to implement a series of measures through April 2008 to cope with recent surge in demand for public hospital services due to seasonal influenza. Public hospitals have been experiencing a prolonged increase in emergency demand lately, in particular the emergency medical admissions, HA Chief Executive Shane Solomon said.

"Compared with February last year, the daily number of emergency medical admissions is 16 percent higher. At the same time, recent admission to pediatric wards in public hospitals has also surged," he said.

The sudden and unprecedented surge in demand in medical and pediatric wards has created great pressure on the front line staff. To cope with the recent surge, various hospital clusters have opened extra beds and implemented other initiatives to cope with patient needs.
(ProMED 3.15.08)

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Indonesia: H5N1 avian influenza and H3N2 seasonal influenza co-infection in Indonesian teenager
Indonesia: H5N1 avian influenza and H3N2 seasonal influenza co-infection in Indonesian teenager An Indonesian teenager was identified as a case of simultaneous infection with seasonal and avian strains of influenza—a possibility that health planners have long warned could give rise to a pandemic flu strain.

In a paper presented on Mon 17 Mar 2008 at the International Conference on Emerging Infectious Diseases, Vivi Setiawaty of Indonesia's Center for Biomedical and Pharmaceutical Research and Development described the case of a 16-year-old girl who was tested for flu in Jakarta in April 2007 under a flu-surveillance system established in 2005 by the Indonesian Ministry of Health.

The girl, who had been experiencing flu symptoms for several days, was only mildly ill, with a 100.5 F fever, sore throat, cough, headache, and body aches, but no difficulty breathing and no signs of pneumonia (case reports of H5N1 patients in countries such as Thailand have described more dramatic clinical presentations). Throat and nasal-swab samples that were taken on the sixth day of her symptoms tested positive by reverse-transcriptase polymerase chain reaction (RT-PCR) for both avian influenza H5N1 and the seasonal flu strain H3N2 at the Indonesian National Institute of Health Research and Development. Serology test results were less clear. Antibody titers from serum samples taken the sixth day provided a weak indication of H5N1 infection (titer of 1:10) but were negative for H3N2; convalescent sera, on the other hand, gave a strong indication of H3N2 infection (titer of 1:640) but were negative for H5N1. Eijkman Institute for Molecular Biology in Jakarta, an arm of the Indonesian Ministry of Research and Technology, confirmed the test results, according to the paper. The girl's case fell within the period when the Indonesian government was not sharing flu isolates with the international laboratory system maintained by the World Health Organization, and there was no indication whether her isolates were evaluated outside the country.

"This is the first case-report of a human with both influenza A/H5N1 and H3N2 co-infection," the paper states. "Such infections are of great concern due to the possibility of genetic re-assortment leading to the emergence of a H5N1 strain that is more easily transmitted human to human, and emphasizes the importance of advanced laboratory-based surveillance in geographic regions where both human and avian influenza viruses are co-circulating."
(ProMED 3.19.08)

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Laos: Government officials report a new outbreak of H5N1 avian influenza in poultry
Government officials in Laos reported a fresh H5N1 outbreak in chickens in Luang Namtha, in the northwestern part of the country near the border with China and Myanmar. Yong Chanthalangsy, the country's foreign ministry spokesman, said that 800 birds were destroyed in a two-mile [3.2km] radius around the affected village, and that the outbreak is the sixth to strike the area in the past month. In mid-February 2008, Laos reported that the H5N1 virus had reemerged in poultry after about a year's hiatus.
(ProMED 3.20.08)

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Viet Nam (Quang Nam): H5N1 avian influenza outbreak in ducks
About 300 ducks have died of bird flu in the central province of Quang Nam. Tests on the dead birds from a Thang Binh District farm were positive for the H5N1 virus. Local authorities incinerated all the infected ducks and destroyed chickens from nearby farms. The Zone Four Agency of Animal Health also confirmed bird flu in Quang Nam. Bird flu cases have previously been reported in the provinces of Quang Ninh, Hai Duong, Nam Dinh, Tuyen Quang, Ninh Binh, Vinh Long, Phu Tho, Ha Nam, and Hanoi. Under local government regulations, a province is considered clear of bird flu if no new cases are reported during a 21-day period.
(ProMED 3.17.08)

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Americas
USA: US has enough H5N1 avian influenza vaccine for 13 million people
A progress report released on 20 March 2008 says the US government has stockpiled enough pre-pandemic H5N1 influenza vaccine for 13 million people, more than double the number listed in the previous report, issued in July 2007.

The report on pandemic preparations by the Department of Health and Human Services (HHS) also says the government plans to release a new version of its pandemic vaccine allocation plan, after considering comments at a series of recent meetings and forums. The 16-page report from HHS Secretary Mike Leavitt lists a wide range of HHS pandemic preparations. It emphasizes the agency's efforts to collaborate with other stakeholders in tackling problems like vaccine allocation and who should bear the burden of stockpiling supplies such as face masks, respirators, and antiviral drugs. The report also says that HHS has acquired enough antiviral drugs to treat 40 million people, or about 80 percent of the agency's goal of 50 million. Officials want the states to buy enough additional doses with the help of a 25 percent federal subsidy to treat another 31 million people.

The report also says HHS:

  • Has awarded 27 contracts worth $3.5 billion since 2005 to develop plans and begin projects in its medical counter measures program
  • Has invested more than $130 million in research on vaccine adjuvants (substances that boost the immune response to a vaccine)
  • Plans to study the knowledge, attitudes, beliefs, and communication message needs of vulnerable groups, such as the homeless and non-English-speakers, with the aim of developing messages about community mitigation measures for combating a pandemic.

(CIDRAP 3.20.08)

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USA: New patch boosts immunity to H5N1 avian influenza
A skin patch helped boost a bird flu vaccine so well that people appear to be protected by a single dose, researchers at biotechnology firm Iomai said.

The so-called adjuvant patch, to be used with an injected vaccine, could help stretch the supply during a pandemic, the Maryland-based company said. Current approved vaccines against the H5N1 avian influenza virus require two doses to be fully effective.

Iomai is testing its adjuvant patch on 500 volunteers in a phase 1/2 trial looking at the safety and efficacy of the patch. The patch is applied after gently scraping the skin with a light sandpaper-like device. It is used to boost an H5N1 vaccine made by the Belgian drug company Solvay. When used with a single dose of the 45-microgram H5N1vaccine, 73 percent of those tested had what is considered a protective immune response. About 49 percent of those who got the vaccine alone, without a patch, had an immune response considered protective after the first dose.

"The prospect of being able to immunize during a pandemic with a single dose is very attractive," said Iomai's chief scientific officer Gregory Glenn, whose company got a $128 million grant from the National Institutes of Health to test the patch.

At least 16 companies are testing H5N1 vaccines but no one knows precisely what a pandemic strain of the virus would look like or how to formulate the best vaccine. Tests on the current vaccines suggest that people need bigger doses than with seasonal influenza. Global flu vaccine production capabilities are limited and if bigger doses are needed, that means fewer people could be vaccinated in a pandemic.

"A one-dose pandemic flu vaccine is a very important advance," Glenn said. "There is just almost no way to immunize twice in the face of a pandemic."

Keeping the right records and counting people to show up twice are both barriers, he said. Adjuvants are frequently used to boost vaccines and some of the experimental H5N1 vaccines include adjuvants in the formulation.
(Reuters 3.20.08)

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China (Guangdong): Officials report H5N1 avian influenza outbreak in poultry
An outbreak of bird flu in poultry has been reported in south China's Guangdong Province, the Ministry of Agriculture (MOA) said on 16 Mar 2008. The National Bird Flu Reference Laboratory confirmed the case, which occurred at a market in Liwan District of Guangzhou City on 13 Mar 2008. The disease, which killed 114 domestic fowl and led to the culling of another 518, was brought under effective control after the MOA and provincial government took timely emergency measures. It was China's fifth bird flu outbreak in poultry in 2008.
(ProMED 3.17.08)

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Viet Nam: Vietnamese child dies from H5N1 avian influenza, country's 106th case/52nd death
Viet Nam's National Hygiene and Epidemiology Institute said the country's latest human case of bird flu infection was an 11-year-old boy from northern Ha Nam province, who died on 14 Mar 2008 after four days of treatment in Hanoi capital. The institute's tests showed that the boy from Thanh Liem district was infected with bird flu virus strain H5N1. The boy became ill on 5 Mar 2008, and was admitted to the Ha Nam General Hospital in the province on 8 Mar 2008, and the National Hospital of Pediatrics in Hanoi on 11 Mar 2008. The WHO has since confirmed the case.

In late February 2008, 10 birds out of a chicken flock raised by the boy's family fell ill and died gradually. Then, his family slaughtered some healthy chickens of the flock for meals. Relevant provincial agencies have disinfected and detoxified the affected area, and selected samples from fowls in the area for bird flu testing.
(ProMED 3.17.08)

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2. Infectious Disease News

Asia
Australia (New South Wales): Rise in mosquito-borne illnesses prompts bite warning
Health authorities are warning people to protect themselves against mosquito bites following a three-fold increase in mosquito-borne viruses in the first two months of 2008. There were 380 cases of Ross River virus in New South Wales (NSW) in January and February 2008, up from 78 for the same period last year. Barmah Forest virus cases almost doubled to 121 over the same period, and more are expected in March 2008 as the mosquito season peaks. Recent rainfall has been blamed for the explosion in mosquito numbers and cases of the viruses, which cause debilitating symptoms such as tiredness, sore and swollen joints, rashes, and fever.

The potentially fatal Murray Valley encephalitis virus (MVEV) has been detected in mosquitoes and chickens in Griffith, Leeton, and the Macquarie Marshes. In rare cases the virus can also be transmitted to humans by mosquitoes, causing permanent brain damage and death.

"There have been no human MVEV infection cases to date, however the monitoring program results means there may be the potential for people to become infected if bitten by a mosquito," said Mr. Jeremy McAnulty, NSW Health director of communicable diseases. He urged people traveling throughout the state over Easter to take precautions such as wearing insect repellent and loose clothing; and avoiding going outside around dusk and dawn particularly when fishing, camping, or bush walking.
(ProMED 3.17.08)

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Australia (Queensland): Measles outbreak spreads to mine workers
A highly contagious measles outbreak has spread to a large mine west of Cairns, where up to 300 workers may have to be vaccinated against the virus. Two miners in their 20s fell ill with the disease during the week of 3-7 Mar 2008. One was so sick he had to be put in isolation in Cairns Base Hospital. He was released from isolation on 10 Mar 2008. One of the men is believed to have picked up the disease from an unknown carrier in mid-February when he visited a large Cairns shopping center. The same carrier at the same time is believed to have passed on the virus to an unrelated high school student, who then went on to infect three other students from Cairns and Kuranda. The miner returned to the mine site, about a four hour drive west of Cairns, and infected a fellow unvaccinated worker.

Tropical Population Health Network Medical Director Dr. Jeffrey Hanna said the shopping center was the only common link between the four infected students and the two miners. He said it showed how contagious the disease was. The discovery of the first four locally acquired cases of the disease in 11 years prompted urgent warnings from public health authorities for people to be on the lookout for measles symptoms.

Although none of the students—two girls and two boys aged between 12 and 15—had to be treated in hospital, Dr. Hanna said three were very sick. The bigger concern was that they had been highly mobile while at their most contagious, using public buses, visiting two of Cairns' biggest shopping centers, a large popular Cairns restaurant, a swimming carnival, and a large party in the Kuranda area. Dr. Hanna said the two miners had not interacted outside the mine site during this early stage.
(ProMED 3.14.08)

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Australia: Number of dengue fever cases rising in Port Douglas
The potentially deadly dengue fever tally in Port Douglas has risen to 14. Health officials on 7 Mar 2008 revealed that the infection rate of the disease continues to climb, despite mosquito traps laid around the town and spraying at sites where dengue has been reported. Public Health officials again called for residents to crack down on mosquito breeding sites. Dozens of houses and apartments around Port Douglas have been included in dengue warning zones, including residences and shops in streets surrounding Macrossan St.

In the center of Mossman, streets to the west of Front St, between Grogan and Harper St, have been declared a warning zone. In 2003, more than 30 people contracted dengue in the inner-Cairns suburb of Parramatta Park, and a 1997-98 outbreak struck down 500 people in the Cairns and Port Douglas area with dengue fever.
(ProMED 3.9.08)

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Philippines (Laguna, Iloilo): Typhoid outbreaks sicken thousands, deaths reported
The Department of Health (DOH) - Center for Health Development 6 (CHD 6) regional director Lydia-Depra Ramos alerted residents of the city of Iloilo against typhoid fever due to the increasing number of suspected cases since the start of 2008. DOH - CHD 6 reported a total of 217 suspected typhoid fever cases with one confirmed fatality and three more deaths subject for further validation in Iloilo City from 1 Jan to 8 Mar 2008. Data showed that most of the typhoid fever cases come from the City Proper District, ages ranging from one to 68 years old with a median of 11 years old. The environmental survey showed that the area is thickly populated. It also pointed out the possible sources of infection as the following: contaminated wells; water from water system due to seepage through leaking pipes; water sold by water vendors; and possible ingestion of contaminated food from food establishments and ambulant food vendors.

In another outbreak (Laguna Province) contaminated water triggered the outbreak of typhoid fever that has downed nearly 2,000 people and killed a 14-year-old girl in Calamba City, health secretary Francisco Duque III said on 10 Mar 2008. Tests showed that the water supplied by the Calamba Water District contained the salmonella bacteria and did not have enough chlorine to kill the microbes, he said. Duque said the number of people with typhoid fever had gone down to 876 from a high of 1800, but the health department could not yet declare that the outbreak had been contained. The department said earlier it suspected that the city's reservoir had been contaminated, but officials of Calamba's water district on 10 Mar 2008 claimed that the city's water was safe for drinking.
(ProMED 3.12.08)

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Thailand (Prachuap Khiri Khan): Economy reports first case of Tularemia
The Public Health Ministry on 17 Mar 2008 declared tularemia an emerging disease in Thailand after its first victim was diagnosed in Prachuap Khiri Khan. Disease Control Department Director-General Thawat Sundarachan said a 37-year-old woman who suffered from cancer was Thailand's first tularemia, or rabbit fever, fatality. Tularemia is a disease borne by rodents and rabbits, and is endemic in North America and Europe.

Dr. Thawat said the woman, whose name was withheld, had kept a number of rabbits in her house and could have been infected by Francisella tularensis, the bacterium that causes the disease, probably through an aerosol of body secretions from her infected pets. Dr. Thawat dismissed concerns about an outbreak, saying that there is no threat of human-to-human transmission and that relatives of the dead, who live under the same roof, should not worry. Cancer might have made the woman too weak to fight the disease, he said.

The ministry is waiting for the results of another lab test from the United States to see if the rabbit fever is of strains A or B, which are more dangerous. The chief of the public health office in Prachuap Khiri Khan, Pipop Janesuthivejjakul, appeared unshaken by the news of the disease. He said the public should not panic over the news of the woman's death, which took place in Kui Buri district in October 2007. The provincial office knew of no other victims in the country.
(ProMED 3.18.08)

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Americas
Canada (Chilliwack): Health officials report five cases of lab-confirmed mumps
Fraser Health is reporting five lab-confirmed cases of mumps in Chilliwack, in the wake of larger outbreaks in Alberta.

"It's been coming at us from east to west," said Fraser Health Medical Health Officer Dr. Gillian Arsenault, who pointed to cases documented in Nova Scotia, and later Alberta. "Apparently some of those infected (in Chilliwack) had either direct or indirect contact with the Alberta connection. So for anyone planning to go to Alberta, now is a good time to get vaccinated."

The local cases are likely just the tip of the iceberg given the "sneaky" nature of the mumps virus, she said. The virus is spread by saliva, so a cough or sneeze can send it traveling through the air with fine mist droplets.

"When we have lab-confirmed cases, it means there are more cases we don't know about," said Dr. Arsenault. "The reason for that is roughly one-third of infected people display no symptoms at all. For them it's just like a rotten cold." Another third of sufferers will experience swollen glands, testicles, or some other physical clue, and the swelling always comes on the heels of the cold-like symptoms. An individual who's been exposed can be infected and not know it, she said. "It only takes one coughing infected person in an ER or waiting room to spread the virus."

Asked if she thought British Columbia's population was immune enough to stop an outbreak, "We don't know," she said. Small clusters of mumps cases have been reported in other communities over the past year, which didn't in fact turn into larger outbreaks of the virus. "We're hoping the same will happen here," said the health official. "We don't know how fast or how big this iceberg is, so it's a good time to get the word out. The more people know, the more likelihood it won't turn into a big outbreak." Mumps "very rarely" kill people, she said, but they can fall ill and feel awful.

A total of 399 cases were reported in Alberta between 1 Sep 2007 and 4 Mar 2008, with the majority of cases in the Chinook region of southern Alberta, and the rest in Calgary. There were also outbreaks in Nova Scotia. "It shows we're not completely immune," said Arsenault.
(ProMED 3.11.08)

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Canada: Eight family members sickened by unknown illness
There were no immediate answers on 5 Mar 2008 about what could have made eight family members on a flight to Canada from the Caribbean so sick that the plane had to make an unscheduled landing in Florida. The eight on Montreal-based Air Transat's Flight 477 from the Dominican Republic to Edmonton began sweating, trembling and hyperventilating after takeoff. A male family member said the family was about to leave when one young woman started getting sick at the hotel and became increasingly ill as they all waited in the airport. Her symptoms spread, seemingly through touch, after the plane had taken off.

"Whatever sickness they had, as soon as someone touched them, and caressed them, cuddled them, or comforted them, they got sick as well, within 20 minutes, half an hour."

The plane was diverted to Fort Lauderdale late on 4 Mar 2008, and the eight were transferred to hospital. They included the man's 14-year-old nephew, the only one who had complained of stomach problems, and one of his daughters, a paramedic who had been treating the others. All were released by the time the flight finally resumed and landed in Edmonton around 8:30 a.m. on 5 Mar 2008.

The families had all eaten at the same place on 4 Mar 2008. But the man said not everyone who ate at the restaurant got sick, and although some of the young adults had been drinking alcohol, his brother-in-law who doesn't drink was also ill. Greg Meyer, an airport spokesperson in Fort Lauderdale, Florida, said officials from the U.S. Centers for Disease Control interviewed everyone on board and determined the sick passengers were not suffering from any airborne illness. Jim Rudolph, a spokesperson at the Edmonton International Airport, said there were no further illnesses reported on the flight once it resumed.
(ProMED 3.9.08)

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USA: Experts closing in on heparin contaminant
Scientists investigating a mystery contaminant in the blood thinner heparin are closing in on what they believe is a counterfeit substance, most likely made in China from animal cartilage, that was chemically altered to act like the real drug.

In interviews, heparin experts in China and the United States, including a researcher involved in the inquiry, said that a chemically altered substance called over-sulfated chondroitin sulfate is probably the contaminant that the FDA says is linked to hundreds of allergic reactions and 19 deaths. Even so, researchers said they were not certain that the contaminant, constituting between five percent and 20 percent of the drug, is what is causing the allergic reactions nor do they know precisely how or when it was mixed into the active ingredient.

Chondroitin sulfate is a widely used supplement to treat joint pain. In its unaltered state, it does not have the blood-thinning properties found in the contaminant. But scientists and researchers say the act of changing the molecule gives the substance anti-coagulating properties. Scientists who have examined batches of the contaminated heparin distributed by Baxter International in the United States said in interviews that they suspected that the heparin-like molecule was intentionally mixed into the drug.

"A child could tell you it's counterfeiting," said Dr. Jawed Fareed, a professor of pathology and pharmacology at Loyola University Chicago, who has been studying batches of heparin since the problems with the drug were discovered. He was conducting his own investigation because he was concerned that the quality problems with heparin were far more widespread than acknowledged.

An American chemist, who asked not to be identified because he had signed a confidentiality agreement, said he and the FDA had looked at chondroitin sulfate as a possible contaminant because of its structural similarities with heparin.

"It is something that is a little bit different," said the chemist, "like a distant family relative you don't recognize. Once we have the exact fingerprint, we will try to figure out how it got into the product."

Zhang Tianmin, 80, a retired professor at the Shandong University School of Pharmaceutical Sciences, said counterfeiters would likely choose chondroitin sulfate or chitosan, from shellfish, as a base substance to create a heparin-like molecule, because both substances are cheap. But since neither has natural blood-thinning activity, counterfeiters would have to add something that does.

"Sulfate groups appear naturally in the heparin molecule," Mr. Zhang said, "but they can also be produced by chemical synthesis."

Baxter has recalled virtually all of its heparin products in the United States. There have been no new deaths since the recall, the FDA said. Dr. Fareed said it was too early to say whether the contaminant is causing the adverse reactions. A variety of reactions have been observed, including abdominal pain, hypotension (low blood pressure), a burning sensation, vomiting, diarrhea, rising temperature, and anaphylaxis, he said, "but one cannot link all of these to one substance."

"This is a deliberate act of chemically manipulating a heparin-like substance and mixing it with heparin to increase the yield," he added. But some batches of heparin containing the contaminant did not elicit adverse reactions, casting uncertainty on their root cause, Dr. Fareed said.
(ProMED 3.20.08)

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USA (Virginia): Imported case of measles worries U.S. health officials
Health workers in northern Virginia are trying to track down hundreds of people who may have been exposed to measles. A 15-month-old child from northern Virginia contracted the disease in India in February 2008. The Fairfax County Health Department was notified of the toddler's condition on 7 Mar 2008. The child had been inside the Harris Teeter grocery store on Woodland Park Drive in Herndon, as well as Fairfax Inova Hospital's emergency room and the Capital Area Pediatrics clinic in Herndon on three occasions. Measles has an average gestation period of three weeks and health workers believe that potentially exposed people would most likely show symptoms by 19 Mar 2008 at the latest. In all, about 500 people may have been exposed to the child. This is the first reported case of measles in Virginia since 2001. No other cases have been reported so far.
(ProMED 3.15.08)

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USA: Officials report three new cases of hantavirus
Officials in three states have reported new cases of hantavirus pulmonary syndrome. A 64-year-old Taos man is dead of hantavirus. The state Department of Health said it was the first case in New Mexico in 2008.

Testing coordinated by the Colorado Department of Health and Environment has confirmed that a Kiowa County man who died in late February 2008 had contracted a hantavirus.

A young Louisiana man has been battling hantavirus since symptoms began in early February 2008. He has been taken off the ventilator and dialysis, and is off all pain medication and antibiotics. Doctors say he probably got it in a duck blind (a cover device for hunters) in his home state of Louisiana.

The often-deadly disease is transmitted through the urine, droppings or saliva of infected rodents—especially deer mice (Peromyscus maniculatus). People contract the disease by breathing in the dried particles infected with the virus. Early symptoms include fever and muscle aches, possibly with chills, headache, nausea, vomiting, diarrhea, abdominal pain, and cough. Symptoms develop within one to six weeks after exposure. There is no specific treatment for hantavirus, but health officials say the chances for recovery are better with early medical attention.
(ProMED 3.8.08 & 3.10.08 & 3.12.08)

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USA (Arizona): Second case of measles confirmed at Northwest Medical Center
A second case of measles at Northwest Medical Center has been confirmed. The case is linked to a previous case, which was traced to a tourist from Switzerland who was at the Northwest emergency room on 12 and 13 Feb 2008, according to a Pima County Health Department news release. The second case was a patient in the emergency room at Northwest, on 12 or 13 Feb 2008 who was later diagnosed with measles, readmitted and treated in isolation between 24 and 26 Feb 2008.
(ProMED 3.8.08)

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USA (Nebraska): Progressive inflammatory neuropathy in pork plant worker
A former meatpacker in Nebraska has the same neurological condition that has struck workers at pork processing plants in Minnesota and Indiana, and that sparked a nationwide disease investigation in November 2007. The Nebraska case is the first in that state. Like the other workers, the Nebraska meatpacker, who has not been identified, worked at a processing plant that uses a high-pressure air system to remove brains from pigs, Nebraska health officials said.

The newest case brings the total number of workers known to be affected to 14. Officials said that as the investigation continues to look into past workers at all three plants, they expect to find more cases. Those affected have reported fatigue, numbness, and tingling in their arms and legs with a wide range of severity. Some have recovered and returned to work, while others are severely disabled. Officials are calling the condition progressive inflammatory neuropathy, or PIN. Most of those affected worked at Quality Pork Processors in Austin, MN, where the condition was first recognized, and two have been identified in Indiana. Nebraska officials declined to say which plant employed the meatpacker, but the only plant in the state that uses the high compression system is owned by Hormel Foods, based in Austin.
(ProMED 3.7.08)

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3. Updates
AVIAN PANDEMIC INFLUENZA

(UN; WHO; FAO, OIE; CDC; Health Canada; CIDRAP; PAHO; USGS)

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Indonesia (FAO report)
The prevalence of avian influenza in Indonesia remains serious despite containment efforts undertaken by national authorities and the international community, FAO warned. Indonesia is the country worst hit by avian influenza.

“The human mortality rate from bird flu in Indonesia is the highest in the world and there will be more human cases if we do not focus more on containing the disease at source in animals,” said FAO Chief Veterinary Officer Joseph Domenech. “I am deeply concerned that the high level of virus circulation in birds in the country could create conditions for the virus to mutate and to finally cause a human influenza pandemic. The avian influenza situation in Indonesia is grave—all international partners and national authorities need to step up their efforts for halting the spread of the disease in animals and making the fight against the virus a top priority.”

31 provinces affected
Avian influenza has become deeply entrenched in Indonesia with 31 out of 33 provinces being infected. The virus is endemic in Java, Sumatra, Bali, and southern Sulawesi with sporadic outbreaks reported from other areas. Since the first outbreaks in 2003 avian influenza has spread rapidly across Java into Bali, Kalimantan, and Sumatra. In 2006 the virus spread further east infecting Papua and much of Sulawesi. About 20 percent of the chicken population of 1.4 billion is scattered in 30 million backyards, where people raise poultry for food or income. Despite major control efforts, the country has not succeeded in containing the spread of avian influenza in poultry, Domenech said.

“Indonesia is facing an uphill battle against a virus that is difficult to contain. Major human and financial resources, stronger political commitment and strengthened coordination between the central, province, and district authorities are required to improve surveillance and control measures,” he said

Major constraints
A highly decentralized administration, under-resourced national veterinary services, lack of engagement with commercial poultry producers, insufficient international and national financial and human resources for control campaigns and the challenges of implementing a comprehensive communication strategy are the major constraints the country is facing, he noted.

“We have also observed that new H5N1 avian influenza virus strains have recently emerged creating the possibility that vaccines currently in use may not be fully protecting poultry against the disease. This issue is being addressed by the Indonesian Ministry of Agriculture with technical assistance from OFFLU (OIE/FAO Influenza Network of Laboratories) and funding provided by USAID and AusAID. Also required are more investigations and the development of better poultry vaccines,” Domenech said. “The major challenge is to immediately apply the main components of a successful national avian influenza control strategy, based on effective surveillance, emergency culling and compensation, vaccination, improved biosecurity, effective laboratory and quarantine procedures, and movement controls of poultry and poultry products.”

Support
FAO is supporting the Indonesian authorities in most of these areas. In addition, the agency has helped to train local teams of animal health professionals in participatory disease surveillance and response (PDS/R). So far, more than 1,350 local government PDS/R officers have been trained and are actively working with village communities to prevent and control avian influenza. Surveillance and response teams are currently working in 193 out of 448 districts in Indonesia. By June 2008, over 2,000 surveillance and response teams will be active in more than 300 districts in disease-endemic areas of the country. Other FAO activities include the provision of technical and policy advice to the HPAI Campaign Management Unit, support to communication strategies, the implementation of market chain studies and research activities. Major donors, such as USAID, AusAID, Japan and the Netherlands, together with FAO, have so far invested more than 25 million US dollars in supporting national control efforts.
(FAO 3.18.08)

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4. Articles
A survey of knowledge, attitudes and practices towards avian influenza in an adult population of Italy
Giuseppe G, Abbate R, et al. BMC Infectious Diseases. 2008;8:36. doi:10.1186/1471-2334-8-36
http://www.biomedcentral.com/1471-2334/8/36

Background
Several public health strategic interventions are required for effective prevention and control of avian influenza (AI) and it is necessary to create a communication plan to keep families adequately informed on how to avoid or reduce exposure. This investigation determined the knowledge, attitudes, and behaviors relating to AI among an adult population in Italy.

Methods
From December 2005 to February 2006 a random sample of 1020 adults received a questionnaire about socio-demographic characteristics, knowledge of transmission and prevention about AI, attitudes towards AI, behaviors regarding use of preventive measures and food-handling practices, and sources of information about AI.

Results
A response rate of 67% was achieved. Those in higher socioeconomic classes were more likely to identify the modes of transmission and the animal vehicles for AI. Those older, who knew the modes of transmission and the animal vehicles for AI, and who still need information, were more likely to know that washing hands with soap before and after touching raw poultry meat and using gloves is recommended to avoid spreading of AI through food. The risk of being infected was significantly higher in those from lower socioeconomic classes, if they did not know the definition of AI, if they knew that AI could be transmitted by eating and touching raw eggs and poultry foods, and if they did not need information. Compliance with the hygienic practices during handling of raw poultry meat was more likely in those who perceived to be at higher risk, who knew the hygienic practices, who knew the modes of transmission and the animal vehicles for AI, and who received information from health professionals and scientific journals.

Conclusions
Respondents demonstrate no detailed understanding of AI, a greater perceived risk, and a lower compliance with precautions behaviors and health educational strategies are strongly needed.
(CIDRAP 3.19.08)

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A broadly protective vaccine against globally dispersed clade 1 and clade 2 H5N1 influenza viruses
Hoelscher MA. Singh N, et al. The Journal of Infectious Diseases 2008;197:000–000
http://www.journals.uchicago.edu/doi/abs/10.1086/529522

Abstract
Development of effective and immunogenic vaccines against highly pathogenic avian influenza H5N1 viruses with the potential to cause a pandemic is a public health priority. The global demand for a vaccine cannot be met in the event of an influenza pandemic because of the limited capacity to manufacture egg-derived vaccines as well as potential problems with the availability of embryonated eggs. Thus, there is an urgent need to develop alternative, egg-independent vaccines. We developed an adenoviral vector–based vaccine that contains hemagglutinin protein from clade 1 and clade 2 viruses, as well as conserved nucleoprotein, to broaden the vaccine coverage against H5N1 viruses.
(CIDRAP 3.19.08)

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Current and future antiviral therapy of severe seasonal and avian influenza.
Beigel J, Bray M. Antiviral Res. 2008;78(1):91-102. Epub 2008 Feb 4.

Abstract
The currently circulating H3N2 and H1N1 subtypes of influenza A virus cause a transient, febrile upper respiratory illness in most adults and children ("seasonal influenza"), but infants, the elderly, immunodeficient and chronically ill persons may develop life-threatening primary viral pneumonia or complications such as bacterial pneumonia. By contrast, avian influenza viruses such as the H5N1 virus that recently emerged in Southeast Asia can cause severe disease when transferred from domestic poultry to previously healthy people ("avian influenza"). Most H5N1 patients present with fever, cough, and shortness of breath that progress rapidly to adult respiratory distress syndrome. In seasonal influenza, viral replication remains confined to the respiratory tract, but limited studies indicate that H5N1 infections are characterized by systemic viral dissemination, high cytokine levels and multiorgan failure. Gastrointestinal infection and encephalitis also occur. The licensed anti-influenza drugs (the M2 ion channel blockers, amantadine and rimantadine, and the neuraminidase inhibitors, oseltamivir and zanamivir) are beneficial for uncomplicated seasonal influenza, but appropriate dosing regimens for severe seasonal or H5N1 viral infections have not been defined. Treatment options may be limited by the rapid emergence of drug-resistant viruses. Ribavirin has also been used to a limited extent to treat influenza. This article reviews licensed drugs and treatments under development, including high-dose oseltamivir; parenterally administered neuraminidase inhibitors, peramivir and zanamivir; dimeric forms of zanamivir; the RNA polymerase inhibitor T-705; a ribavirin prodrug, viramidine; polyvalent and monoclonal antibodies; and combination therapies.
(CIDRAP 3.14.08)

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The Southeast Asian Influenza Clinical Research Network: Development and challenges for a new multilateral research endeavor
Higgs ES, Hayden FG, et al. Antiviral Res. 2008;78(1):64-8. Epub 2007 Nov 20.

Abstract
The Southeast Asia Influenza Clinical Research Network (SEA ICRN) (www.seaclinicalresearch.org) is a recently developed multilateral, collaborative partnership that aims to advance scientific knowledge and management of human influenza through integrated clinical investigation. The partnership of hospitals and institutions in Indonesia, Thailand, United Kingdom, United States, and Viet Nam was established in late 2005 after agreement on the general principles and mission of the initiative and after securing initial financial support. The establishment of the SEA ICRN was both a response to the re-emergence of the highly pathogenic avian influenza A (H5N1) virus in Southeast Asia in late 2003 and an acknowledgment that clinical trials on emerging infectious diseases require prepared and coordinated research capacity. The objectives of the Network also include building sustainable research capacity in the region, compliance with international standards, and prompt dissemination of information and sharing of samples. The scope of research includes diagnosis, pathogenesis, treatment and prevention of human influenza due to seasonal or novel viruses. The Network has overcome numerous logistical and scientific challenges but has now successfully initiated several clinical trials. The establishment of a clinical research network is a vital part of preparedness and an important element during an initial response phase to a pandemic.
(ProMED 3.12.08)

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Ecology of H3 avian influenza viruses in Korea and assessment of their pathogenic potentials
Song MS, Oh TK, et al. J Gen Virol. 2008;89:949-957; DOI 10.1099/vir.0.83462-0 http://vir.sgmjournals.org/cgi/content/abstract/89/4/949

Abstract
To determine the genetic origins of novel H3 avian influenza viruses of chickens and ducks in Korea, genetic characterization of H3 avian influenza viruses isolated from live poultry markets and migratory aquatic birds in South Korea during 2004–2006 was conducted. Phylogenetic analysis revealed that at least four novel genotypes of H3N2 and two genotypes of H3N6 avian influenza viruses were co-circulating in backyard poultry of Korea. The viruses were reassortants between H9N2 viruses of Korean chickens and unknown influenza viruses of migratory birds. Genetic comparison of H3 viruses from live bird markets with those from wild bird isolates revealed that certain gene segments of wild bird isolates are related closely to those of Korean group H9N2 viruses isolated from live poultry markets in 2003. Furthermore, animal-challenge studies demonstrated that the pathogenicity of certain avian H3 influenza viruses was altered due to reassortment, leading to H3 avian influenza viruses in Korea that can potentially expand their host range to include mammals. These studies emphasize the continuing need to monitor backyard poultry at live poultry markets to better understand interspecies transmission and the emergence of novel influenza viruses that have the potential to infect humans.
(CIDRAP 3.10.08)

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5. Notifications
APEC EINet Pandemic Influenza Preparedness Virtual Symposium: Partnerships and Continuity Planning for Critical Systems
APEC EINet is pleased to host a special videoconference on pandemic influenza preparedness. This videoconference is a follow-up to our first “virtual symposium”, which was conducted in January 2006 with great success (participating economies were Australia, Canada, China, Korea, Philippines, Singapore, Chinese Taipei, Thailand, USA, and Viet Nam). You can view a five-minute video clip of our previous virtual symposium at: http://depts.washington.edu/einet/symposium.html. Our upcoming videoconference will be held in late May 2008. It will take place during the evening hours of 29 May in the Americas and in the morning hours of 30 May in Asia, for approximately 3.5 hours. Our objective is to describe how private and public sectors in the APEC region can cooperate and work effectively to prepare for and respond to an influenza pandemic.

Through this videoconference, we hope to promote regional information sharing and collaboration to enhance pandemic preparedness. In order to improve preparedness regionally, it is vital to understand how each economy in the region is undertaking this task. In this process, EINet will:

  1. Bring together economies in a dynamic, real-time discussion on preparedness through the collaboration of the health and the business/trade sectors, with a focus on critical systems continuity.
  2. Share specific examples of current practices—e.g. scenario exercises, communication drills and policy evaluation.
  3. Use innovative technologies (e.g. Access Grid) for real-time, virtual interchange, enhancing their utility for future collaboration and response in the event of a pandemic.
Videoconferencing offers an alternative to in-person conferencing. It cuts down on the time and cost of traditional conferences requiring long-distance travel. Simultaneous communication with multiple sites is possible, with numerous visualization options. Real-time web-based information exchange is also possible, and, during an actual pandemic, the virtual medium would be a safe way to communicate when international travel is limited or prohibited.

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13th International Congress on Infectious Diseases (ICID)
http://www.isid.org/13th_icid/

Date: June 19-22 Location: Kuala Lumpur, Malaysia Venue: Kuala Lumpur Convention Center

The meeting in Kuala Lumpur hosted by the Ministry of Health, Malaysia will again welcome delegates from over 100 countries. The program will include plenary talks by world-renowned experts in the science of infectious diseases and important topics critically presented by international luminaries in the field. Moreover, there will be great opportunities to spend time with leaders in the field, exchange ideas, and develop collaborations with scientists from distinguished medical centers around the globe. All who are committed to the prevention and control of infections worldwide will find this a compelling meeting that should not be missed.

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HHS includes online services in pandemic communication drill
The US Department of Health and Human Services (HHS) recently held a tabletop exercise to assess how it could best work with the news media—including blogs and other online-only information sources—to get status updates and vital health information to the American people during an influenza pandemic. The session was held on Mar 17 at HHS headquarters in Washington, DC. Representatives from online avian-flu information services such as Avian Flu Diary, FluTrackers, FluWiki, WebMD, and CIDRAP News participated in the exercise along with those from several national media organizations, including ABC News, National Public Radio, and Reuters.

The exercise was the second time HHS has reached out to blogs. In May 2007, the department featured posts from bloggers such as Michael Coston of Avian Flu Diary and Greg Dworkin, MD, of FluWiki in a five-week pandemic preparedness blog series. HHS Secretary Mike Leavitt hosts his own blog on the HHS Web site. He is the first cabinet secretary to use the online forum, according to HHS.

Bloggers were also included in a one-day leadership conference that HHS hosted to engage community leaders in talking about local preparedness efforts and seek input on how to tailor HHS's own resource materials. "We recognize that during a pandemic information could be life-saving. As more and more people turn to the Internet for information and news, blogs have emerged as an important and influential communications tool," HHS said in its invitation to attend the tabletop exercise.

Federal officials at the table included HHS Secretary Leavitt and representatives from the Centers for Disease Control and Prevention (CDC), Department of State, Department of Homeland Security, and the Coast Guard. Representatives from state health departments and healthcare facilities also took part in the exercise, because they will also be fielding questions from the media and online sources throughout an influenza pandemic, and especially at the beginning.

Details about the pandemic exercise were off the record, but the scenario featured intensified activity overseas that prompted the World Health Organization to raise its pandemic alert stage. The situation then progressed to one suspected H5N1 case in the United States, which led to dozens of cases in major cities on both coasts. At several points during the exercise, moderator Forrest Sawyer, a former news anchor with ABC and NBC, asked the news media and online outlets to predict what their headlines would be and what information they would need from HHS, CDC, and other agencies. During the exercise the communications officials from HHS floated the idea of "embedding" some of their staff in media organizations to ease access to official information during a pandemic. The agency also said its media access policies now treat reputable blogs and other reputable online services the same as traditional media organizations.

Stephanie Marshall, director of pandemic communications at HHS, said that because growing numbers of people are going to online sources for news and information, "It's important for the government to understand how best to work with bloggers and other online journalists to distribute information. The exercise and the insights offered by the participating bloggers will help us improve and refine our existing pandemic communications plan."
(CIDRAP 3.19.08)

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 apecein@u.washington.edu